A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?
Explanation & Rationale
A. Use frequent touch to provide client support could be distressing for a client experiencing paranoid delusions or hallucinations. Touch might be perceived as threatening or invasive, increasing anxiety or mistrust. It's important to respect personal space and maintain a calm, non-threatening environment. B. Place the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention for hallucinations. Seclusion should only be considered in cases of extreme agitation or safety concerns, and other de-escalation techniques should be explored first. Isolation can increase distress for clients with schizophrenia. C. Limit the number of questions asked during assessments is a good approach. Clients with schizophrenia who experience hallucinations or paranoid delusions may become overwhelmed or agitated if there are too many questions. Keeping communication simple, clear, and concise helps prevent overwhelming the client and minimizes confusion or anxiety. D. Directly tell the client that delusions are not real is not recommended because doing so may lead to resistance or cause the client to feel invalidated. Instead, it's more appropriate to acknowledge the client's feelings or experience without confirming or denying the delusions. For example, saying something like, "I understand that you're feeling that way, but I am here to help you stay safe," can be more therapeutic.